COVID-19 in Children: Clinical Approach and Management- Correspondence
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CORRESPONDENCE
COVID-19 in Children: Clinical Approach and Management- Correspondence
Received: 19 May 2020 / Accepted: 29 May 2020 # Dr. K C Chaudhuri Foundation 2020
To the Editor: We were pleased to read the well-written article in this journal entitled COVID-19 in children: clinical approach and management by Sankar J et al. [1]. We would like to commend the authors for a timely and succinct article on approach to management of pediatric COVID-19, providing essential and practical guidance to clinicians, and would like to comment on the management of COVID-19 in light of recent evidence, available studies and guidelines. We are in the midst of an unprecedented global COVID-19 pandemic and though illness in children is usually mild, a small fraction can develop severe disease. The therapeutic approach for managing critically ill patients with Acute respiratory distress syndrome (ARDS)/ respiratory failure centers around lung protection with low tidal volumes, high positive end-expiratory pressures and fluid restriction. Anticoagulation is required in presence of high D-dimers or evidence of thromboembolism. A variety of therapeutic agents for COVD-19 are under evaluation, with approximately 78 vaccine and 600 therapy related trials taking place worldwide. A recent study showed the antiviral Remdesivir, a nucleoside-analog that acts by inhibiting viral replication, to be effective in the majority of treated critically ill adult patients [2]. A recent multicenter expert pediatric guidance panel has recommended Remdesivir as the preferred antiviral agent in children if available [3]. Another therapeutic alternative for management in children is Hydroxychloroquine (HCQS), which can be used if Remdesivir is not available [3]. HCQS has been shown to be effective against SARS CoV-2 in in-vitro studies, considered relatively safe in children, and is also suggested by authors in the management approach. Of note, HCQS in combination with Azithromycin has been associated with greater risk of cardiac adverse effects and QTc prolongation, therefore, this combination
is not recommended in children [3]. Other antivirals like 5-Fluorouracil, Ribavirin and Favipiravir, in treating COVID-19 by inhibiting the coronavirus’ RNA proteins from making genomic copies of the novel coronavirus, are being studied as well. Although, Lopinavir/ Ritonavir was found to be of no benefit in one study as rightly noted by the authors [4], results of the World Health Organization SOLIDARITY trial evaluating these are awaited [5], and the pediatric panel neither recommends for /against its use [3]. The combination of Lopinavir/Ritonavir and Ribavirin is not recommended, given concern for serious adverse effects [3]. Convalescent plasma from recovered patients has been shown to be beneficial in critically ill patients [6] and given the accompanying cytokine storm with COVID19, IL-6 (interleukin-6) inhibitors like Tocilizumab are being increasingly utilized [7]. Other drugs like Famotidine are under study and low-dose steroids have been used in ad
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